My experience of being a student on my first placement...

My first placement in Malta was in the Intensive Care Unit (ITU). ITU is a unit that care for patients with life-threatening conditions whom need constant care, close monitoring and support form equipment and medication to keep normal body functions going. The unit uses specialised monitoring and treatment equipment and staff are highly trained in caring for the most severely ill patients http://www.ics.ac.uk/patients___relatives/what_is_intensive_care_).

As usual going into a new setting is nerve racking, as you never know what to expect let alone in a a different country, which have a different language, a different way of living and a different way of caring for people. As a matter of a fact I assure you, it was more than I expected. When I first arrived on ITU the first thing I noticed was the wires and technical machines and equipment attached to patients, I was then introduced to the Nursing Officer (a title we do not have in the UK) and was given a day that I was expected to come in and meet my mentor. On my first day my mentor was not around however, I was allocated to another staff to work with. This member of staff showed me around, introduced me to other staff and we began the shift after handover. It was my first time in the ITU as did not know what to expect. Not long after I discovered that patients that came into ITU was either semi-concisions,sedated or in a coma following a trauma, multiple organ failure or needed respiratory support.

At the time of this placement, I was also undertaking a class on Critical care with Maltese students. Taking the class was beneficial as ITU as a placement I had never been, it helped put theory into practice, it allowed me to visualise evidence based practice and reflective learning. Taking the class also boost my confidence and allowed me to practice effectively. The topics covered in class included caring for a patient in shock, infection prevention and control, care of the patient with burns, haemodynamic monitoring, electrocardiogram monitoring, arterial blood gasses monitoring, pulmonary oedema, airway management, mechanical ventilation and caring for the head injured patient. Below is a picture of the lecture and my colleagues:

During the placement I was able to take participate in taking arterial blood gasses, manage invasive ventilation, monitor vital signs, practice documentation, provide care for the critically ill (including, skin care, oral care, IV, SC and IM medication and many others), assist families, attend other investigations such as CT scans, X-rays and MRI scans. I learnt so in both class and in practice that I would have never imagined and will always be with me. I felt as part of the team, I listened to discussion on patients, ethical issues that had to be dealt with in-relation to dying with dignity, removing life support etc. I also got the chance to spend a day in critical areas such as the renal unit, the critical cardiac unit, the neonatal and paediatric unit and the burns and plastic unit. Below is a picture of me caring for a sick patient under supervision:The intensive care unit involved working along side, Doctors (Consultants, Registers, Specialist House Officers), Anaesthetists , Pharmacists, Nursing Officers and Nursing staff. There were also medical allied staff including physiotherapist, ECG technicians and radiotherapist who saw patients regularly. This shows that there were a number of different health professionals in the multi disciplinary team who worked well and closely together.

During my time in ITU I was also given the chance to visit the critical cardiac unit (CCU), the renal unit, the burns and plastic unit and the neonatal and paediatric unit (NPICU). The cardiac unit is a nurse led unit, it has 6 beds and on the day of the visit it had two critical patients. They were both post op; these patients usually come in following a general aesthesia cardiac operation such as a bypass, valve replacement, a heart transplant any many more. With these patients they usually came from ITU with a propofol infusion, an analgesia infusion, a urinary catheter, a drain and mechanical ventilation via an ETT. The nurses are usually ITU trained and are able to manage such equipment. These patients are monitored constantly; they have ECG leads, an arterial line, and central venous line. Fluid for maintenance, a cardiac output machine, pulse oximetry, saturation probe and a temperature probe. On one of the patients was a pulmonary arterial line which measures the pressure (PAP) on the right side of the heart and on the other patient was a machine called the inter aortic balloon pump, is a mechanical device that decrease the myocardial oxygen demand while at the same time increase cardiac output. It is used commonly for previous suffers of a M.I and post bypass, it has its risks however; it lowers the risk of an embolism. Other major complications associated with cardiac problems are stroke and kidney problems. These can hinder us to from certain interventions which can be beneficial to the patient e.g. If a patient who has CHF develop kidney problems, the heart will then increase its work load causing further problems or if a patient has too low of a blood pressure and has renal failure, dialysis which will ultimately benefit the patients may not be taken into consideration. Thus, depending on the patient the appropriate care is given and what is best for the patient will be at the heart of any decision. Patients with heart conditions usually have other health problems such as dyslipidemia, diabetes, asthma, obesity etc. They are advised to take care of their diet, exercise and be compliant with medication. Over all, this placement what short yet interesting. 

The NPICU has always been an area which has always been difficult for me to work and as I have a 'soft spot' for children and seeing them unwell is extremely hard for me. This NPICU took babies from birth to 1year old, these babies were either premature, had respiration disorders, problems during birth, chromosomes problems, infections, syndromes or were sometimes admitted for close monitoring.  There was also an outpatient which parents brought their babies for treatment and to assess their progress. The inpatient babies were washed, feed and treatment was given in the morning. They were so tiny and cute. The babies were cared for in a machine known as an incubator, the incubator was humidified to retain heat, minimise infection, and protect the babies and kept them warm. Some of these babies were critical and had to be intubated for ventilation. Like adults these babies had where regularly monitored, their blood pressure, pulse, saturation were checked hourly. Some also had an umbilical arterial blood pressure (IABP) measured which bloods were taken from however, unlike the adult ABG’s their dead space of two millilitres blood was given back to them. There was this particular baby who was on a ventilator, born at 28 weeks but look liked 200 pounds, her mother was an immigrant and was 15 years old. The baby was very unwell and it seemed there was not much more that could be done for her. A week later I went back to see the baby and she was still there fighting for her life. She was said to be doing much better and had gain a bit of weight, I cried with joy. NPICU is my weakest emotional point which needs working on, however my time there was well spent. 

Another place I visited was the renal unit, the renal unit had a critical outpatient setting for patients with renal failure. This unit had different departments for different types of dialysis. The functions of kidneys are vital, they eliminate water, wastes and waste products such as excess potassium and sodium, creatin and urea. They produce vitamin D, red blood cells in the bone marrow and controls blood pressure via homeostasis. The red blood cells maintain our haemoglobin and if its low erythropoietin (EPO) is given. EPO is an artificial hormone. There are three kinds of accesses for dialysis; these are the tenchkopf via the peritoneum which is used in CAPD and APD (these will be explained further) and then there is the fistula (upper limbs), graft (an artificial tube), permcath (femoral, subclavian or jugular veins) and vascath (the same as the permcath but temporally). These last four are used for haemodialysis where their patients come into the unit 2-3 times a week for the haemodialysis machine to ‘clean’ their blood. The haemodialysis machine is connected via an artery and a vein. The needle is inserted into the access by the arterial line which is always away from the heart and then the venous line which is towards the heart. The arterial blood is usually red and thick whilst the venous line is usually dark, the blood is taken from the arterial line through the machine filtered and heparinised and returned via the venous line. The machine usually has heparin, saline, water for osmosis, a filter and a chamber which clotting can be observed. The procedure usually last for 4 hours and BP is measured during the dialysis. The CAPD/APD is used in independent patients whereby a bag is attached to remove the toxins and a high concentration of dextrose is administered, this usually takes up to twenty minutes to achieve. It is done up to twice a day and an APD machine all night. The reason of choice for these patients are based on their knowledge and understanding, an assessment, venous access, patients desire or choice, lifestyle and access availability such as veins. This placement was very informative as I had never worked in renal but had dealt with renal patients and had never fully understood the concept. It made me feel like some of us take things for granted because they are restricted to what they eat, drink and do. If I could do anything differently I would have like a longer placement. Having visited these different areas I gained incite to as to what they do on a day to day bases and dealt with my emotions when working with babies and young children. 

Overall, I was on the ITU placement for approximately ten weeks and after six weeks I remember feeling confident as day in and day out and no two days were the same however, I saw young people, vulnerable people and older adults come in and some did not survive. Some were taken of life support because all that could have been done had been done for these patients. This mad me feel sad, it made me think it could happen to any one of us and our families. After 10 weeks on there it felt daunting and stressful having to care for extremely sick people. What I kept thinking was this could be me, it made me miss my family and not want to take life for granted. However, if I had the chance to take another ITU placement, I would grasp it without a thought and make the most out of it. What I would have done is grasped on much more as I possibly can.This placement taught me a lot, medically, personally and spiritually and for that I will always be grateful.